Harm Reduction Implementation and HIV/AIDS within

Injecting Drug Users

Alena Rose
Sowk 673
January 5, 2014
Table of Contents:

I. Introduction
1. Methodology

II. Need For Harm Reduction Practices
1. Peer Based Harm Reduction
2. Needle Exchange Programs/Needle Syringe Programs
3. Safe Injection Facilities
4. Opiate Substitution Programs/Methadone Management Programs
5. Harm Reduction for the Incarcerated
6. Systemic Understanding
7. Funding

III. Example of Direct Practice
1. Top Down Practice
2. Bottom Up Practice/Grassroots

IV. Criticism of the Literature

V. Conclusion

VI. Literature Review Research























I. Introduction
Harm reduction has become a concept that sparks ideological divides. Since
its inception, harm reduction has invoked a great deal of controversies in its
implementation. Despite personal ideologies regarding the practice, one fact
remains; harm reduction is an effective method in reducing the harm associated
with problematic drug use. When considering the harm related to drug use,
HIV/AIDS is a common outcome for those drug users involved in injection drug use .
HIV/AIDS is a very real risk associated within the injecting drug users (IDUs)
community. The purpose of this paper is to (a) outline current harm reduction
initiatives specific to people living with HIV/AIDS, (b) explore factors that limit
harm reduction practices, and (c) explain current perspectives on the need for
further harm reduction ideologies and practices throughout the world. In reviewing
the literature, one can gather that writers on the issue have taken a very broad
approach to researching a topic that encompasses a diversified population. Given
the diversity of the population and the risks themselves, one can understand the
large scope of the topic.
IUDs have become the fasting rising contractors of HIV/AIDS in the global
north, there are an estimated 13 million IDUs living in our modern world (HIV,
Harm reduction, and Human rights). As one study indicates, the sharing of injection
equipment among IDUs causes one in ten new HIV//AIDS infections. (Wodak and
McLeod, 2008, p.1). There is a distinction between the risk of contracting HIV/AIDS
through sexual transmission and for those at risk through intravenous drug use. For
the purpose of this study, harm reduction for those at risk through intravenous drug
use will be explored.





1. Methodology
In November to December of 2013, literature regarding the implementation
of harm reduction practices for those included in the HIV/AIDS population was
reviewed. Using the University of Calgarys database to search scholarly journals
and articles, the topic was reviewed. All documents published before 2002 were
excluded. Results were produced using the following search terms; harm reduction
and HIV as well as harm reduction, implementation, and HIV. The abstracts from
the results these search terms produced were reviewed. From those reviewed, 19
were included for the review.
The definition of harm reduction in itself is extremely broad. Many writers on
the topic identify this lack of a definitive definition to the variety of information on
the topic. The term harm reduction encompasses concepts, ideologies, policies,
strategies of intervention, targets and movements (Ball, 2007,p.102-103). Given the
nature and variety of the term, the literature is thusly diverse and broad.
Many studies have noted the implications of the ambiguity the definition.
Since the definition of harm reduction itself is unspecific, so are the
implementations of the practice. One writer defines harm reduction as follows;
Harm reduction is a pragmatic approach to reduce the harmful consequences of
alcohol and drug use or other high risk activities by incorporating several strategies
that cut across the spectrum from safer use to managed use to abstinence (Marlatt
and Witkiewitz, 2012, p.591). This definition illustrates the vagueness of the
practice.
Given the lack of a concrete definition, understanding and acceptance of the
concept has been difficult. Even the term harm is subjective. There are a large
number of risks associated with drug use and the harm that can come to individuals
from said behaviors can vary. However, as one writer points out, how can harm be
measured?
Significant work has been undertaken in quantifying health related
harm through such instruments as disability-adjusted life year and
quality of life measures, there is no methodology for objectively
measuring net harm across different domains such as health, social
functioning, and economic development. How does one assess the
net harm to society related to injecting drug use, taking into
account such harms as HIV morbidity and morality, public nuisance
of discarded needles, economic impact, criminal behavior and
moral outrage at permissive drug policies (Ball, 2007, p.686).
Without a clear indication of what exactly the practice is trying to address and the
various impacts the issue takes on, its implementation is clearly affected by its
subjectivity. As Syrachareun and colleagues (2013?) indicate, harm reduction
continues to be an illusive term even in more recent years:
In some instances, the response to harm reduction practices have been met
with misunderstanding. The ambiguity of the definition perpetuates this
misunderstanding. For example, the implementation of harm reduction
practices in Laos (2013) was met with dispute because even the key
informants of the project were indecisive when it came to their definitions of
the practice. While some key informants held the practice as specific to IDUs,
other held a broader definition that included policy and prevention (p.3).
Some stakeholders welcome the lack of a definitive definition. As one writer
explains, It (harm reduction) allows for greater flexibility in implementing policies
and programmes to respond to critical public health problems (Ball, 2007, p.687).
With a broader definition, the nature of the diversity of the population being served
can be addressed. One might argue that a broader scope allows for more flexibility.
Even the notion that prevention and harm reduction are mutually exclusive
can be confusing. The idea that prevention policy is administered with the goal of
preventing the issues from existing while harm reduction addresses the existing
problem. Many countries, such as China, took criminalization as an approach to
prevention and implemented punitive policies surrounding the issue. Later, in
realizing the failures of these approaches, China applied harm reduction policies in
the form of methadone management treatment (MMP) and needle syringe programs
(NSPs) as their prevention model.
In the example of China, harm reduction became a part of their prevention
strategy, incorporating both into their approach. Harm reduction practices include
the implementation of prevention strategies in their application. The two cannot be
dichotomized but rather should be considered mutually inclusive of each other.
Many areas recognize the need for prevention yet still dispute the need for harm
reduction. As illustrated by China, harm reduction is just another form of
prevention.
Although one could agree that a broader definition allows for a wider scope,
one might also suggest a distinct definition for harm reduction is needed in order to
gain a general acceptance of the practice. While prevention is a notion that is widely
accepted, harm reduction is still being met with discomfort. Perhaps specific
definitions of harm reduction practices aimed at the different populations within the
communities the practice serves would encourage acceptance while saving the
broader scope. Further discussion of the methodology used for this paper can be
found within the appendix.


II. Need For Harm Reduction
One of the dominant aspects that is repetitively addressed in the literature is
the indisputable need for harm reduction practices for IDUs. The risk of HIV/AIDS
infection for IDUs is extremely high in this population as sharing of injection
equipment is frequent. In reviewing the literature, it is apparent that there are many
needs for the application of harm reduction practices as well as obstacles that stand
it the way of its implementation.
NEPS, SIF, MMPS, and peer-based programming are all identified as harm
reduction practices needed to prevent and hinder the spread of HIV/AIDS among
IDUs. The literature also addresses the growing need for access to these programs to
those incarcerated in punitive institutions.



1. Peer-Based Harm Reduction
Forms of grassroots initiatives have been unique in that many of them have
included drug users in their implementation. Peer based support services have been
identified as key components to successful harm reduction programs. Utilizing the
experiences and knowledge of drug users in harm reduction implementation is
invaluable. Given the stigma of drug use, users, especially IDUs, often feel a sense of
shame about their lifestyle choices, making it difficult for them to access services.
Society has taught drug users that because they use drugs, they do not
deserve the same public health services as other community members. Accessing
services can mean the admittance of drug use. The automatic judgment that can
occur once this has been revealed can create detrimental barriers for individuals.
Drug users have also learned to fear authority, making it more difficult for them to
feel safe in any formalized/professional setting. Through the use of peer-based
services, drug users can feel a sense of security and connection, making access to
services less intimidating. In a world that stigmatizes drug users, peer based
programs offer a chance to deliver services to a population that can be difficult to
reach.
Peer based programs not only offer a sense of comfort for users but they also
provide opportunities for drug users to be involved in the programing of harm
reduction practices. Often times, drug users can offer valuable knowledge that
would otherwise be unknown. As one writer illustrates;
The presence of other women drug users as staff members and
volunteers will make women drug users feel more comfortable and
improve the quality of care. People who use drugs have inside
knowledge that is essential to an informed approach to service
provision and policymaking. (Pinkham and Malinowka-Sempruch,
2008, p.173-174).
The outcomes of peer-based harm reduction programs can be constructive
for both programmers and clients.
The benefits of peer-based programs are significant. In Brazil, the use of
peer-based educators was a pivotal aspect to the implementation of their project.
Program planners employed the buddy system for active drug using peer-based
educators in order to maintain the ethical obligation to remain sober during
program hours (Domanico ad Malta, 2012, p. 538). Project managers defined several
key success related to their presence such as accessing a larger audience, key insight
to hot spots, and knowledge regarding need (e.g. what kind of crack pipes will be
realistically used) (Domanico ad Malta, 2012, p. 538).
Other programs have witnessed similar successes. In the case of harm
reduction programing for HIV/AIDS risks associated with IDUs in New York,
NYCAIDS Institute introduced a model for secondary syringe exchange peer-
delivered syringe exchange enabling IDUS visiting syringe exchange programs to
provide syringes through their social networks and IDUs not visiting the programs
(Heller and Paone, 2011, p. 146).


2. Needle Supply Programs/Needle Exchange Programs
There is a decisive agreement among those involved in harm reduction
practices addressing HIV/AIDS in IDUs. The implementation of harm reduction for
this population is very specific. As the UN illustrated in their endorsement of making
sterile injecting equipment available, the access to clean needles is one of the harm
reduction practices identified.
When considering the lifestyle of many IDUs, the sharing of needles is a
common occurrence. Given the nature of the deviant role one would be living as an
IDU, money, access, and availability of clean needles increases risks. . Needle syringe
programs (NSPs) and Needle exchange programs (NEPS), provide users with access
to clean needles. The reality of many IDUs is that without access to clean needles,
sharing becomes a viable and realistic option.
NSPs and NEPs have become a common form of harm reduction practices
and have had great implications for the communities they serve in and for. NSPs and
NEPs both address not only the risks to IDUs themselves but also the communities
they reside in. Finding used needles in parks and alleys is a common occurrence
amongst communities with high rates of IDUs. NSP are effective in increasing the
use of sterile injecting equipment and decreasing the chances of injecting equipment
being reused (Wodak and McLeod, 2008, p.4).
The availability of NSPs and NEPs around the world varies. From the
literature, one could gather that of all the harm reduction initiatives, NSPs and NEPs
have been the most widely accepted and implemented. In one study, researchers
found that the data collected from 103 cites around the world that had NSPs, HIV
prevalence decreased to 18.6% rather than an annual decrease of 8.1% in cities that
did not have NSPs (Wodak and Maher, 2008, p. 2).
This acceptance was not easily gained. 1984 marked the first legal,
government funded, needle exchange program in Amsterdam, to be followed later
by similar projects in Canada, the United States, and Australia between 1980s and
1990s (Marlatt and Witkievitz, 2010, p.596). Today there are is much greater
acceptance and acknowledgements of the benefits of these programs. Researchers
alike have come to the same conclusions;
Eight reviews of the evidence for needle syringe programmes
conducted by or carried out on behalf of the US government
agencies have concluded that these programs are effective in
reducing HIV and are unaccompanied by serious unintended
negative consequences (including inadvertently increasing illicit
drug use). More recent reviews commissioned by the World Health
Organization (WHO) and the US National Academy of Science came
to the same conclusions. (Wodak and McLeod, 2008, p. 4).
From the literature, the evidence and need for NEPS and NSPS is
indisputable. As the literature illustrates, the ideologies that assume harm
reduction efforts promote drug use are proven wrong in several studies.

3. Safe Injection Facilities
Another form of harm reduction that is deployed as a means of reducing the
harm and risk of HIV/AIDS for IDUS are Safe Injection Facilities (SIFs). These
facilities are a lot less prevalent in comparison to other forms of harm reduction
methods like NSPS and tend invoke a great deal of controversy. These facilities offer
IDUs a place to inject drugs under the supervision of nurses and medical staff. From
the literature, it can be observed that this method alone is not as effective as other
programs, it does offer significant factors in the cessation of the issue.
Providing clients with the sterile equipment as well as a clean and safe space
to use drugs offers a variety of benefits for IDUs. Many drug users are given no other
choice but to use drugs in unsafe spaces, especially for those IDUs who are
experiencing homelessness. A common occurrence for this population entails using
drugs in unhygienic spaces. Since this type of action is portrayed as deviant in our
society, the injection of drugs and the supplies needed to do so can become risk
factors in themselves. Given that our society often dehumanizes this population,
they are often give no other option than to use in alley ways in highly unhygienic
environments.
Using unclean water, which is then injected into the body, frequently occurs
in these types of settings. In addition to this, trying to find a vein while squatting
behind a dumpster, constantly looking over their shoulders for police does not allow
for optimal injection. These are just some of the issues associated IDUs who are
experiencing homelessness. SIF help to prevent many of the risks associated with
these issues.
There are several government funded SIFs located around the world today.
Spain, Norway, Netherland, Luxembourg, Canada, and Australia are just some of the
countries that have recognized the benefits of such programs (Marlatt and
Witkiewitz, 2010, p.596). European countries have accepted and adopted the
implantation of SIFs since the 1980 (Reddon et al, 2011, p.413) while Canadas SIF
in Vancouver is the first and only of its kind in North America. Although progress
has been slow, other SIF have been proposed for some Canadian cities.
Most SIFs offer NSPs in addition to their services. This nurtures a number of
benefits for the population and local community. While offering a space for IDUs to
use drugs that is not on the street, IDUs can access sterile equipment, overdose
response, basic primary care, injecting education, and referrals to treatment
services (Reddon et al, 2011, p.413). SIFs offer a chance to engage vulnerable people
who are likely not to seek services otherwise. In addition to the benefits for IDUs, it
also allow for the broader community to witness a decrease in illegal activities
occurring on the streets by providing a space for IDUs to access.
The effectiveness of such facilities can been found in the literature. As one
writer illustrates At least 28 studies have been published that indicate a significant
reduction in needle sharing and reuse, overdoses, and injecting/discarding of
needles in public places. In addition to this evidence, the case of Insite in Vancouver,
British Columbia, studies also found a 30% increase in detoxification services that in
(Marlatt and Witkiewitz, 2010, p.596). Although these studies do not emphasize a
direct affect on the rates of HIV/AIDS, one can only imagine the impact these
components would have on the overall issue.
An important aspect that is often disregarded when considering SIFs is the
number of lives that are saved on a daily basis. This form of harm reduction
prevents deaths that would have otherwise occurred due to overdose. Whether
HIV/AIDS is a factor, IDUs are still human beings who deserve access to services
that will help them stay alive. Regardless of the choice to become involved in drugs,
at a humanistic level, SIFs acknowledge that IDUs are people with rights who
deserve to be treated as such. While other forms of harm reduction aim to prevent
the ultimate mortality of HIV/AIDS, SIFS in addition to that, work to prevent death
at an immediate level.


4. Opiate substitution treatment/Methadone Management Treatment
The ultimate goal of opiate substitution treatment, otherwise known as
Methadone Management Treatment (MMT) is to help IDUs achieve abstinence from
opiate drug use. These programs have provided another effective approach in
addressing HIV/AIDS within the IDU population in that they assist individuals with
the cessation of injection drug use.
While taking methadone or buprenorphine, individuals no longer experience the
highs of a drug such as heroin but are also able to relieve the intense and sometimes
deadly withdrawals that come with abstaining from opiate use.
One can argue that the continuation of drug patterns can be associated with
the severe withdrawal of opiate use. Although withdrawal occurs within the realm
of all substance use, that of an opiate withdrawal can be more significant. User of
opiates are often trying to elevate the unforgiving pain that comes with abstinence
from the drug. Muscle and body pain, nausea/vomiting, diarrhea, and insomnia are
just some of the symptoms associated with opiate withdrawal. Methadone and
buprenorphine help users by reducing or eliminating these symptoms, making
cessation easier.
One critique of this program is that its use is exclusive to only those with
opiate dependency. Given that there are several drugs that are frequently used
through injection, MMTs do not address other substances. These treatments are also
dependency forming, meaning a user will have to continue use to avoid withdrawal
symptoms. Although the MMPs do not solve the multitude of problems associated
with all IDUs, they do offer a realistic way for individuals to abstain from opiate use,
thus creating the opportunity to reduce the risks associated with injection drug use.
NSPs/NEPs, SIFs, and MMPs are all identified as needed programs in
combating the spread of HIV/AIDS infections amongst IDUs. These programs
provide various benefits inside and outside the realm of HIV/AIDS. The literature is
very clear in the need for these harm reduction programs. Each program is not
without its own critiques, however, regardless of their criticisms, have been proven
both health and cost effective in their implementation.
One study from an Australian NSP illustrated; for every dollar invested in
NSPs, more than four dollars was returned in direct health-care cost-savings within
ten years (Wodak and Maher, 2008, p.2). An important and regretfully astonishing
finding from the literature is the lack of cost effective studies proving the savings
involved in harm reduction programs for HIV/AIDS in the IDUs population. Some
evidence can be found but in order to sway the proponents of harm reduction, the
costs and savings of such programs should be clearly addressed.



5. Harm reduction for the incarcerated
From the literature, there is a notable need for the harm reduction practices
outlined previously in prisons around the world. Writers on the subject have all
identified the concerning lack of services for those incarcerated. Injection drug use
is extremely prevalent in criminal institutions. The notion that those placed in
prison would abstain from drug use while incarcerated is ignorant and ignored the
reality of the issue. Given the nature of criminalizing drug use in our current society,
the number for IDUs in prisons is significantly high.
The prevalence of HIV in prisons around the world is notably high. One study
illustrated that 10% of individuals incarcerated in South Africa, Xambia, Burkina
Fasco, Cameroun, Cote dIvoire, Gabon, Malawi and Rawands are HIV/AIDS positive
(Raguin et al, 2011, p.1131). This high rate of individuals with positive HIV/AIDS
results in concerning given the condition and lack of services for those incarcerated.
With a lack of appropriate harm reduction practices available to those individuals,
potential risk is inevitable for IDUs.
Women are identified as being at greater risk for HIV/AIDS while
incarcerated. As one writer outlines; According to UNODC, the proportion of drug
users among female prisoners is higher than male prisoners, injecting drugs with
shared equipment is particularly common among female prisoners and HIV rate
among female prisoners is higher than among male prisoners (Pinkham and
Malinowska-Sempruch, 2008, p. 172). Given no other option, IDUs would rather
share injecting equipment than abstain from using.
Given the conditions of most prisons, it would make sense that an individual
would reject abstinence and accept risk. Many of those in correctional institutions
were IDUs before they were incarcerated. As one writers explains;
Increasing reliance of drug law enforcement to control illicit drugs
inevitably means that more IDUs will spend larger proportions of
their drug injecting careers in correctional institutions, but with so
little to lose, high risk drug injecting often continues. Once behind
bars, the risk of acquiring HIV infection is further increased by
multiple factors including the large number of injecting equipment
sharing partners, the severely degraded conditions of needs and
syringes and the mixing of diverse demographic and geographic
groups in prisons (Wodak and McLeod, 2008, p.7).
With nothing left to lose, drug use could be a logical escape for those living in
correctional institutions.
The risk associated with injecting drug use in correctional facilities could be
easily addressed. Through the implementation of similar harm reduction practices
such as NSPs and NEPs, the rates of HIV/AIDS could be significantly decreased.
However, like harm reduction practices in the general population, resistance is
seemingly customary. The false ideologies that harm reduction will promote and
offer acceptance of drug use is held. Harm reduction practices are often disregarded
in correctional institutions on the grounds that they condone criminal behaviors
(HIV Harm Reduction and Human rights).
As with many prohibition policies, people will still make the decision to take
drugs regardless of the consequences. Those incarcerated are no different. Although
intense measures have been taken to stop drugs from entering correctional
facilities, the realities is that their presence is still there. Efforts of prohibition might
hinder the presence of drugs in prisons, it will not stop the risk of associated with
the sharing of injecting drug equipment (Wodak and McLeod, 2008, p. 7). Without
the acceptance of harm reduction practices in correctional facilities, the rates of
HIV/AIDS infections amongst incarcerated individuals will inevitably increase.

6. Systemic understanding
Systemic institutions have had a great deal of influence in terms of the
implementation of harm reduction practices in general. Given the criminalization
model our world has adopted in response to drug use, those who deviate from this
are met with resistance. Harm reduction practices in general are often met with
misunderstanding and confusion. Since at the core of all harm reduction practices,
meeting the individual where they are at and accepting the reality of their drug use,
compromises the common drug polices and ideologies that the dominant systems
holds.
The literature is clear in the majority of efforts that address drug use in
general as one that takes a legal or medical approach. Given the nature of
globalization, it is not surprising that most the policies of the United Stated
dominate the international perspective. Many similar views to the one the United
States holds have been adopted by many countries worldwide (Marlatt and
Witkiewitz, 2010, p.594). Globalization is a contributing factor that often hinders the
availability of diverse ideas, harm reduction for IDUs are not unique to this notion.
The current policies around drugs are driven by the war on drugs. A focus
on supply control, as well as use-restrictions are the central concern. As one writer
points out;
Over the past 100 years, policies have been imposed that address
both the demand and supply of drugs as well as policies to mitigate
the harms of drug abuse. The ultimate goal both supply reduction
and demand reduction policies is to minimize or eliminate the use
and abuse of illicit drugs, which is not the primary goal of those
policies that are specifically designed to reduce the harms related
to illicit drug use (Marlatt and Witkiewitz, 2010, p.594).
These policies have had serious consequences when considering harm reduction
practices for IDUs. People who engage in drug behaviors have now become part of a
war they, arguably, have nothing to do with.
Policies that promote the war on drugs perpetuate the stigmatization of drug
users. In our current society, drug users are seen as deviants and are forced in to a
criminal role. One might speculate the lifestyle change that would occur if drug use
was not considered deviance but rather a historically common behavior in society.
Although the health affects and risks associated would still exist, it is a curious
thought to imagine how drastically different an IDUs experience would be without
them being viewed as criminals.
Further examination of drug policy presents issues surrounding
Some writers suggest that policies surrounding drug use should be revised.
The acknowledgement of more humanistic perspective is suggested (Marlatt and
Witkiewitz, 2010, p.594). One writer suggested that one systemic institution such as
the International Narcotics Control Board (INCB) should adjust their policies to
meet the needs of the individuals affect by them;
The INCB needs a new membership which (1) recognizes that
harm reduction is consistent with drug control conventions, (2)
respects human rights, and (3) conducts transparent deliberations.
Only these measure will foster harm reduction policies in countries
where control of HIV is a public health priority (Harm Reduction
and Control in HIV IDUs in France).
The focus of human rights and the acknowledgement of additional approaches need
to occur in order for harm reduction methods for HIV/AIDS IDUs to prosper. The
war on drugs has been the most costly and longest war in history. As many of come
to conclude, its a losing war for all parties involved.



7. Funding
Without systemic understanding, one of the biggest deterrents of successful
harm reduction practices for HIV/AIDS IDUs is a lack of funding. Not all, but a large
majority of countries do not make available funds for harm reduction practices. This
leaves organizers of the practice with scarce resources to provide services.
Typically, more money is focused in the areas of policing and prohibition than into
harm reduction strategies, leaving it difficult for programs for IDUs to maintain
themselves. One might argue, a lack of funding contributes to increased levels of
HIV/AIDS infections within the IDU population.
The literature identifies a lack of funding as a significant barrier to providing
IDUs with harm reduction practices. Even in countries with who hold a positive
views of harm reduction still struggle to find adequate funding (Wodak and McLeod,
2008, p.6). Wodak and McLeod (2010) identify that funding is an issue for both the
global south and north (p.6). Regardless of the cost effectiveness of such programs,
governments are still not considering IDUs as in their funding strategies.
For example, Australia, who has had a relatively positive view of harm
reduction practices, have also fallen into the pattern of ignoring the need for
funding. In 2002/2003, of the $3.2 billion budget, government officials allotted only
5% of that to harm reduction and 62% of it to drug enforcement (e.g. police, court,
probations, and prisons). Similarly, Canada focused 93% of its budget on law
enforcement (Wodak and McLeod, 2008, p.9). These funding patterns speak to the
lack of appropriate funding experienced at the grassroots levels.
Given the influence the global north has on an international level, one might
conclude that the actions of the United States have had a lasting impact on the lack
of funding that exists for harm reduction practices. Until 2009, the United States had
a ban on federal funding for NEPS (Marlatt and Witkiewitz, 2010, p. 596). Until this
time, the United States had yet to acknowledge the effectiveness of harm reduction
practices in reducing HIV/AIDS rates. This new perspective will hopefully influence
other countries to reconsider their own policies surrounding harm reduction
practices.
Two studies of projects aimed at serving HIV/AIDS IDUs identified funding as
major barriers of the success of their practice. Many of these programs require
trained professional staff that require compensation for their work. This in addition
to the cost of the space, equipment, and supplies, contribute to high costs. One
project identified the inability to appropriately pay staff as a challenge found in their
research (Mund, et al, 2008, p.949). Another study echoed that same issues;
The discontinuation of fund was a key challenge reported by all
program managers, and the lack of alternative donors influenced
high turnover rates of trained staff (more than 60% of trained
personnel quitted their outreach work activities before ending the
first fiscal year), therefore jeopardizing the intervention of
effectiveness (Domanico and Malta, 2012, p.540).
Without adequate funding, programs are left to suffer the consequences, leaving
vulnerable IDUs at risk for many factors, including HIV/AIDS.
A lack of law enforcement support was also identified as a major challenge to
one of the studies done. In Brazil, during a study that addressed harm reduction for
crack users, project managers identified police harassment as a common
occurrence. Police and media opposition was frequent ((Domanico and Malta, 2012,
p. 541). One might gather that some law enforcement bodies place those who work
of drugs users in similar deviant roles as the users themselves.
A lack of systemic understanding has influence many key factors
contributing to harm reduction practices, especially those aimed at preventing the
spread of HIV/AIDS in IDUs. Policy has been highly influential in funding and law
enforcement. Without a wider acceptance felt by the larger systems, harm reduction
practices will continue to face barriers and implementation will continue to suffer
the consequences.

III. Direct Practice
The need for harm reduction in addressing HIV/AIDS risks for IDUs is further
examined in the examples of direct practice. The literature examines several
program studies that address harm reduction strategies for HIV/AIDS in IDUs. Some
of the initiatives varied in the effectiveness of their study, however, the positive
outcomes largely outweigh the negative. The literature provides explicit examples of
harm reduction implementation for HIV/AIDS risks to IDUs in both bottom-up and
top-down approaches.

1. Top Down
The literature is very clear in the existence of some top down policies in
relation to harm reduction practices. Although the majority of the examples of harm
reduction practices occur at a grassroots level, there is a distinct acceptance from
the Assembly of the United Nations (UNAIDS/UNODC) and the World Health
Organization (WHO). These bodies have recognized the need for harm reduction
practices in response to HIV in IDUs and have devised strategies to address and aim
to decrease the prevalence of the issue.
The turn of the twenty first century came with invaluable progression for
harm reduction practices, first by the UN and than later by WHO. In 2001, the UN
general assembly encouraged countries to make harm reduction services related to
drug use available (Ball, 2007, p.685). In the realization that prohibition policy was
not addressing the death rates of HIV/AIDS in IDUs, the UN made it one of their
missions to ensure access to sterile injection equipment for people who use drugs
(Csete and Wolfe, 2008, p.1). With the support of the United Nations, harm
reduction for IDUs began to gain acceptance.
Later, in 2003, the World Health Organization (WHO) furthered this progress
when all 192 member states advocated for a global health sector strategy that
encompassed harm reduction as a core response to HIV/AIDS (Ball, 2007, p.686).
Subsequently, WHO furthered harm reduction practices after reviewing the
evidence of NSPs, giving them reason to strongly suggested the following; All
countries affect or threatened by HIV/AIDS among IDUs should rapidly establish
and expand NSPs to the scale of the affected population (Wodak and Maher, 2010,
p.69).
The United Nations Assembly has also realized the important outcomes
opiate substitution programs provide. In recognition of the beneficial attributes of
such programs, the UNDCP, UNAIDS, and WHO all endorsed opiate substitution
programs. Addition to this, WHO included methadone and buprenorphrine, two
drugs used in substitution of opiates, in a list of essential medicines (Wodak and
McLeod, 2008, p. 5). This acceptance has lead to widely implemented MMPs around
the global north.
Given these top down policy suggestions, one could assume the prevalence
of harm reduction in relation to HIV/AIDS in the IDU population. However,
regardless of the endorsements made by the UN and WHO, the implementation of
harm reduction for this population is still slow and even non-existent in some
countries. Ultimately it is still at the discretion of the country to employ harm
reduction as a strategy for addressing HIV/AIDS within the IDU population.
Consequentially, this has left a many areas of the world without a realistic and
valuable practice.
Other top down policies that can be found exist in South America. Here
business owners employ harm reduction strategies to help contrast impacts
HIV/AIDS has on their employees. Once infected with HIV/AIDS, workers
productivity significantly decreases for well-known reasons. Through the use of
prevention and education, corporations in South Africa have implemented these
strategies to help reduce the impact HIV/AIDS can have on the work place (Bolton,
2008, p.280). This unique perspective has offered many employees the opportunity
to reduce their risk of HIV/AIDS. This particular strategy is not directed exclusively
to those at risk through IDU transmission, however their efforts could be translated
just the same.



2. Grassroots
Grassroots organizing has been pivotal in the establishment of harm
reduction practices around the world. One of the most significant examples came
from New York. The group of individuals who fought for their right to access clean
needles is a compelling example of work that can be done. As one writer explains,
the activists and the advocates have been the primary catalysts for the progression
and expansion of syringe access policies and practice in NYC (Heller and Paone,
2011, p.140).
The remarkable work between 1984 and 2010 by New York advocates has
had instrumental influence on the risks associated with HIV/AIDS and IDUs (p.141).
Through the use of civil disobedience, activists refused to accept the lack of harm
reduction and handed out clean syringes regardless of law enforcement threat. With
the help of IDUs themselves, the Association for Drug Abuse Prevention and
Treatment (ADAPT) was formed and announced plans to distribute sterile syringes
despite out dated laws prohibiting the distribution of paraphernalia (p. 141).
Through their refusal to accept injustice, this movement helped pave the way
for a now prosperous harm reduction community. After 25 years, New York is now a
shinning example of harm reduction practices addressing HIV/AIDS for IDUs. Mayor
Bloomberg, in 2003, stated; the sky has not fallen. Drug use and drug related crime
have not gone up. In fact, they have gone down (p.145). In New York, grassroots
initiatives have been able to achieve their goals and influence the larger systems, a
victory some would say is very hard to achieve.
Although Insites grassroots origins are not specifically addressed in the
literature regarding the program, Insite is another outstanding example of harm
reduction community development. Similarly to activists in New York, drug users in
Vancouver demanded their own form of harm reduction. Through civil
disobedience, in the form of a coffin carried into a city hall meeting, community
members made it known that a SIF was desperately needed. IDUs of Vancouver
refused to be ignored and through community building and initial grassroots
programing, the only SIF in North America is now a exemplary model for harm
reduction advocates.
The presence of top-down/bottom-up models of harm reduction programs
varies. Due to an overall lack of universally accepted harm reduction practices, one
might assume initiatives get their start from enthusiastic groups individuals at
grassroots levels however this is not always the case. As strong push from
influential NGOs have had positive affects in that they have push, not all, but some
governments to take action in the form of harm reduction.
Other tops down models exist in the world, as shown in the example of South
Africa. South Africa offers a unique perspective in that they acknowledge the cost
benefits of harm reduction practices. Feeling the impacts of HIV/AIDS, South African
businesses started offering prevention and education programs as a way to combat
the strain they felt from workers affected by HIV/AIDS (Bolton,2008, p. 282). By
recognizing that productivity in the work place is greatly affected by HIV/AIDS,
efforts have been employed to help recover some of the impacts. Top down harm
reduction policies have been implemented in South Africa and in such, have created
a shining example of the cost and human benefits of such programs.

IV. Critique
Although the literature examines a great number of countries that have
adopted harm reduction policies, there is a clear underrepresentation of the global
south in the literature. Information regarding HIV/AIDS in the global south is little
to non-existent. While the issue exists within all regions of the world, there is little
evidence that show any efforts to help combat HIV/AIDS, especially within the IDU
population. While one study illustrates, 78% of IDUs live in developing transitional
countries, 95% of methadone consumed in developed countries, and more than half
was consumed in the United States as of 2002 (Schumacher, Fischer, Qian,2007, p.
301). As shown, harm reduction efforts are making their way through the global
north, however the south, as the literature illustrates, the remaining 22% have yet
to feel the same benefits.
Efforts are not non-existent in the global south however further research is
needed. Drug use occurs in all regions of the world. The need for harm reduction
practices the global south is detrimental. The environment in those areas pose even
greater risk than in countries of the global north. However, there are still many
regions of the world that refuse to even acknowledge drug use within their
boarders, let alone provide harm reduction practices for its citizens .
Other area that the literature ignores is the lack of accountability the UN and
WHO have had in regards to policies surrounding harm reduction. Both
organizations have set forth recommendations for harm reduction practices, yet the
literature addresses nothing in regards to those countries that ignore their
recommendations. These top down policies are important but only if they are to be
put into action. Talking about harm reduction is helpful but actually doing it is
where the real benefits lay.


V. Conclusion
Given the diverse nature of harm reduction practices and those that benefit
from their outcomes, the research is thusly also diverse. Although the research is
wide in scope, it is clear that harm reduction programs for those who are at risk for
HIV/AIDS through IDUs is greatly needed. From Safe injection facilities to
methadone maintenance programs, harm reduction programs have proven effective
not only in decreasing the further spread of HIV but offering those already affected,
the same basic public health rights others are given.
There are many great lessons to be learned from those programs that have
sough to address the HIV/AIDS issues among IDUs. Through perseverance at a
grassroots level, to accountability for those top down policies that exist, harm
reduction is a slow battle that must be won. Ideologies are often the antagonist of
many harm reduction programs. Society needs to stop dehumanizing drug use and
than perhaps harm reduction programs can do what they are designed to; save lives.




Searches for peer-reviewed journal articles and dissertations were conducted using the University of Calgary online databases
in the area of all studies. These searches are outlined below. The Google Scholar search engine was also used in order to
conduct more general searches. All searches were limited to research with humans, published in English, between present
time and 2004

The following searches were conducted:
Data Base Searched Terminology in Abstract Articles Selected
U of C (all collections):
ScienceDirect, ScioINDEX, Social
Services Abstract, Social Work Abstract,
Health Source, CINHAL, SFXhost, et al.
HIV and Harm Reduction


17
GoogleSchoolar Harm Reduction and HIV 2





Reference:
Ball, A. L., , , & , (2007). HIV, injecting drug use and harm reduction: a public health
response. Addiction, 102(5), 684-690. Retrieved from
http://onlinelibrary.wiley.com/store/10.1111/j.1360-
0443.2007.01761.x/asset/j.1360-
0443.2007.01761.x.pdf?v=1&t=hq2vw8ft&s=45e6f177b3cdf3eecb34ca030231a6fb
312c1269
Bolton, P. (2008). Corporate responses to hiv/aids: Experience and leadership from south
africa. Business and Society Review, 113(277), 300. Retrieved from
http://onlinelibrary.wiley.com.ezproxy.lib.ucalgary.ca/store/10.1111/j.1467-
8594.2008.00321.x/asset/j.1467-
8594.2008.00321.x.pdf?v=1&t=hq2ugeta&s=112ead0c79a49be385c20439caf9311
988c31f93
Carrieri, P. M., & Spire, B. (2008). Harm reduction and control of hiv in idus in france. The
Lancet, 372(9637), 448. Retrieved from
http://www.sciencedirect.com.ezproxy.lib.ucalgary.ca/science/article/pii/S014067
3608611952
Csete, J., & Wolfe, D. (2008). Progress or backsliding on hiv and illicit drugs in 2008. The
Lancet, 371(9627), 1820-1821. Retrieved from
http://www.sciencedirect.com.ezproxy.lib.ucalgary.ca/science/article/pii/S014067
3608607771
Domanica, A., Malta, M., & , (2012). Implementation of harm reduction toward crack users in
brazil: Barriers and achievements. Reproductive Health Matters, 47(4), 435-546.
Retrieved from
http://informahealthcare.com.ezproxy.lib.ucalgary.ca/doi/abs/10.3109/10826084.
2012.644170
Heller , D., Paone, D., & , (2011). Access to sterile syringes for injecting drug users in new
york city: Politics and perceptions (1984-2010). Substance Use & Misuse, 46(2-3),
140-149. Retrieved from
http://informahealthcare.com.ezproxy.lib.ucalgary.ca/doi/full/10.3109/10826084.
2011.523319
HIV, harm reduction and human rights. (2005). Canadian Medical Association.Journal,
172(5), 605-605, 607. Retrieved from
http://ezproxy.lib.ucalgary.ca/login?url=http://search.proquest.com/docview/204
998579?accountid=9838
Marlatt, A. G., & Witkieqitz, K. (2010). Update on harm-reduction policy and intervention
research. Annual Reviews, 6(591), 606. Retrieved from
http://www.annualreviews.org.ezproxy.lib.ucalgary.ca/doi/pdf/10.1146/annurev.c
linpsy.121208.131438
Mund, M., Heller, D., Meissner, P., Matthews, D., Hill, M., & Cunningham, C. (2008). Delivering
care out of the box: The evolution of an hiv harm reduction medical program.
Journal of Health Care for the Poor and Underserved, 19(3), 944-951. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686111/
Pinkham, S., Malinowska-Sempruch, K., & , (2008). Women, harm reduction, and hiv.
Reproductive Health Matters, 61(31), 168-181. Retrieved from
http://www.jstor.org.ezproxy.lib.ucalgary.ca/stable/25475377
Schumacher, J. E., Fischer, G., & Qian, H. (2007). Policy drives harm reduction for drug use
and hiv/aids prevention in some developing countries. Drug and Alcohol
Dependence, 91(2-3), 300-305. Retrieved from
http://www.sciencedirect.com.ezproxy.lib.ucalgary.ca/science/article/pii/S037687
1607000774
Reddon, H., Wood, E., Tyndall, M., Lia, C., Hogg, R., Montaner, J., & Kerr, T. (2011). Use of
north america. AIDS Education and Preveion, 23(5), 412-422. Retrieved from
http://www.swetswise.com.ezproxy.lib.ucalgary.ca/swoc-
web/linkingDetails.html?openURL=false&issn=0899-9546&eissn=0899-
9546&volume=23&issue=5&page=412
Sychareun, V., Hansana, V., Phommachanh, S., Somphet, V., Phommavongsa, P., Tenni, B.,
Moore, T., & Crofts, N. (2012). Harm reduction journal. Defining and Redefining harm
reduction in the Loa context, 9(28), Retrieved from
http://www.harmreductionjournal.com/content/9/1/28
Wodak, A., Maher, L., & , (2010). The effectiveness of harm reduction in preventing hiv
among injecting drug users. New South Wales Public Health Bulliten, 21(4), 69.
Retrieved from
http://www.publish.csiro.au/view/journals/dsp_journal_fulltext.cfm?nid=226&f=N
B10007
Wodak, A., McLeod, L., & , (2008). The role of harm reduction in controlling hiv among
injecting drug users. National Institute of Health, 22(2), S81-S92. Retrieved from
http://informahealthcare.com.ezproxy.lib.ucalgary.ca/doi/full/10.3109/10826084.
2011.523319